- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.18 / $828.18 / $1,035.23
| Professional | | $828.18 | $828.18 | $1,035.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,459.40 / $7,459.40 / $7,459.40
| Facility | | $7,459.40 | $7,459.40 | $7,459.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.00 / $4,230.00 / $4,230.00
| Professional | | $675.00 | $4,230.00 | $4,230.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $456.26 / $591.32 / $733.74
| Facility | | $456.26 | $591.32 | $733.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.26 / $733.74 / $811.10
| Professional | | $456.26 | $733.74 | $811.10 |